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Objective: To validate the established normal testosterone to estradiol ratio and characterize the distribution of testosterone to estradiol ratios in a large cohort of fertile and subfertile men., Materials and Methods: Retrospective review of adult men (≥18 years of age) presenting for fertility evaluation between 2002 and 2021 who underwent evaluation by a reproductive urologist, had 2 separate semen analyses and had hormonal testing within 6 months of their index semen analysis. Men were dichotomized into fertile and subfertile groups based on total motile sperm count on 2 semen analyses. The subfertile cohort included men with a total motile sperm count <20 million on both semen analyses. The main outcome measures were serum testosterone, serum estradiol, and serum testosterone to estradiol ratio., Results: Among 816 men, 651 (79.8%) were classified as fertile and 165 (20.2%) as subfertile. Median testosterone (ng/dL) to estradiol (pg/mL) ratios were similar between the groups (14.48 vs 15.00, P = .5). The 20th percentile testosterone to estradiol ratio for the fertile group was 9.77., Conclusion: This is the largest study to date characterizing testosterone to estradiol ratios in men presenting for fertility evaluation. We validated the 10/1 ratio that was previously established as the 20th percentile for fertile men. We found no difference in testosterone to estradiol ratios between fertile and subfertile men defined by total motile sperm count, highlighting the need for further investigation to better define the cohort of men with infertility who could benefit from aromatase inhibitor therapy., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To assess the association between ethnicity and fertility outcomes for men in a statewide cohort., Methods: We linked data from the Utah Population Database and Subfertility Health Assisted Reproduction and Environment database, to comprise a cohort of sub-fertile men who underwent semen analysis between 1998 and 2017 in Utah. A multivariable Cox proportional hazard model was constructed to understand the impact of ethnicity on fertility outcomes in our cohort., Results: A total of 11,363 men were included. 1039 (9.1%) were Hispanic. 39.7% of men in the lowest socioeconomic status group were Hispanic (P <.001). When controlling for demographic and clinical factors, the number of live births was reduced for Hispanic men (hazard ratios [HR] = 0.62 [0.57-0.67], P <.001). Though fertility treatment had a positive effect (HR 1.242 [1.085-1.421], P <.001), in competing risks models, Hispanic men were less likely to use fertility treatment (HR = 0.633 [0.526-0.762], P <.001)., Conclusion: Hispanic ethnicity is significantly associated with a lower likelihood of successful fertility outcomes in Utah. Hispanic men had nearly a 40% reduced likelihood of live births when controlling for sociodemographic factors. Our results indicate that, depending on age, Hispanic men have up to approximately 14 fewer live births per 100 men per year, pointing to a significant disparity in fertility outcomes in the state of Utah. Given 15.1% of Utah's population identifies as Hispanic and 18.7% of the United States population identifies as Hispanic on the 2020 Census, a better understanding of the association of ethnicity and fertility outcomes is imperative., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare the prevalence of abnormal hormone parameters among men with and without oligospermia to determine the value of universal hormonal screening during initial fertility evaluation., Materials and Methods: We retrospectively evaluated men who underwent semen analysis and hormonal evaluation (morning testosterone [T] and follicle-stimulating hormone [FSH]) between January 2002 and May 2021. Sperm concentration was dichotomized at 15 million/mL according to World Health Organization (WHO) criteria. We compared median and interquartile range (IQR) T and FSH levels according to sperm concentration using Kruskal-Wallis test. Differences in prevalence of low testosterone (<300 ng/dL) and abnormal FSH (>7.6mIU/mL) were determined using chi-square test., Results: 1164 men had a morning serum T. There was no difference in median T among men with normal vs abnormal sperm concentration (316 ng/dL, IQR 250-399 vs 316 ng/dL, IQR 253-419; P = .52). FSH was measured in 1261 men. Median FSH was higher among men with sperm concentration <15 million/mL (6.0IU/mL, IQR 3.9-10.7 vs 3.8IU/mL, IQR 2.7-5.7; P < .001). Among men with ≥15 million/mL concentration, 44.1% were found to have low T (P = .874) and 10.8% had an FSH ≥7.6 mIU/mL (P < .001). Among men with ≥15 million/mL sperm concentration who underwent both T and FSH evaluation, 43.6% had at least 1 hormonal abnormality., Conclusion: Almost half of men with normal sperm concentration had low T. As low T may have long-term implications for both fertility and overall health, providers should consider universal T screening in men presenting for fertility evaluation., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To determine whether men with elevated follicle-stimulating hormone (FSH) and normal semen analysis (SA) are more likely to experience a decline in semen parameters over time compared to men with normal FSH., Methods: Men presenting for fertility evaluation between 2002 and 2020 with normal initial SA were dichotomized according to baseline FSH as normal (<7.6 IU/mL) vs elevated (≥7.6 IU/mL). Primary outcomes included the development of abnormal sperm concentration (<15 million/mL) and total motile sperm count <9 million. Secondary outcomes included abnormal sperm motility (<40%), morphology (<4%), and total number of SA abnormalities., Results: The final sample consisted of 858 men; 776 had normal FSH, and 82 had elevated FSH at presentation. Compared to men with normal FSH, men with elevated FSH had lower total motile sperm count (64.1 vs 107.3, P < .001) and higher testosterone levels (339 ng/dL vs 309 ng/dL, P = .03). At each follow-up timepoint, more men with elevated FSH had oligospermia compared to men with normal FSH. Men with elevated FSH were more likely to experience a decline in total motile sperm count below the intrauterine insemination threshold of 9 million and more likely to develop SA abnormalities over time., Conclusion: In men presenting for fertility evaluation with normal index SA, elevated FSH was associated with subsequent decline in semen parameters over time. Men with elevated FSH and normal SA, a condition we have termed compensated hypospermatogenesis, represent an at-risk population for whom close follow-up is warranted., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To assess changes in antibiotic prophylaxis for inflatable penile prosthesis surgery following publication of the American Urological Association (AUA) Best Practice Statement in April 2008., Materials and Methods: The Premier Healthcare Database was queried for inflatable penile prosthesis surgeries from January 2000 to March 2020. The primary outcome was administration of an AUA-adherent antimicrobial regimen and secondary outcome was 90-day explant. Piecewise linear regression was used to compare antimicrobial trends before vs after guideline publication. Multivariable logistic regression models were constructed for primary and secondary outcomes., Results: A total of 26,574 patients who underwent inflatable penile prosthesis surgery were identified, of whom 17,754 (67%) received AUA-adherent antibiotics. After guideline publication, there was a 42% relative increase in AUA-adherent regimen usage, with an increase in the usage trend on piecewise linear regression (from 0.1% to 0.8% of encounters per quarter, R 2  = 0.75, P < .001). Increased usage trends were also observed for gentamicin (from 0.0% to 1.0% of encounters per quarter, R 2  = 0.84, P < .001) and vancomycin (0.1%-0.7%, R 2  = 0.77, P < .001). On multivariable regression, odds of AUA-adherence increased after guideline publication (OR: 1.67, 95% CI: 1.54-1.80, P < .001) and with surgery by a high-volume surgeon (OR: 2.21, 95% CI: 2.07-2.35, P < .01). Nonadherence to an AUA-recommended regimen with use of nonstandard antibiotics (OR: 1.16, 95% CI: 0.78-1.71, P = .5) or excess antibiotics (OR: 0.91, 95% CI: 0.62-1.30, P = .6) was not independently associated with increased risk of 90-day explant., Conclusions: Publication of the AUA Best Practice Statement was associated with subsequent increases in the usage of guideline-adherent antibiotic regimens, particularly vancomycin and gentamicin, despite absence of level-1 evidence supporting this combination., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To study the cost-effectiveness of incorporating home semen analysis in screening for oligospermia and expediting time to evaluation., Methods: A decision analytic model was built using inputs from the medical literature. The index patient is the male partner in a couple seeking fertility, and entry into the model was assumed to be at the inception of the couple's attempts to conceive via natural means. Three main strategies are described and analyzed: (1) baseline strategy of no testing, (2) utilization of a home semen testing kit, (3) universal testing via a clinic visit and gold standard lab semen analysis. The primary outcome was detection of oligospermia (defined as sperm concentration <15 million/mL). Strategies were ranked by months to evaluation by a male infertility specialist saved. Costs were considered from the patient perspective and were incorporated to determine the incremental cost per month saved to evaluation (ICMS) per 100,000 patients., Results: Compared to a baseline strategy of no screening, utilizing a home test would save 89,000 months at the incremental cost of $7,418,000 for an ICMS of $45.51. Shifting to a strategy of universal gold standard clinic and lab testing saves an additional 3000 months but at an ICMS of $17,691 compared to the home testing strategy., Conclusion: Widespread adoption and the early usage of home semen analysis may be a cost-effective method of screening for oligospermia and facilitating further evaluation with an andrology specialist., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To investigate the association between elevated endogenous testosterone levels and deleterious effects associated with testosterone therapy. Elevated serum testosterone levels in men receiving testosterone therapy have been associated with side effects, though precise thresholds above which these occur are unknown. Data on the association between naturally elevated endogenous testosterone levels and their physiologic effects is sparse., Methods: We examined National Health and Nutrition Examination Survey data between 2011 and 2016, analyzing men aged 18 and older not on testosterone or androgen ablation therapy, excluding men who had testosterone <300 ng/dL, to compare men with elevated testosterone (>800 ng/dL) to men with normal testosterone (300-800 ng/dL). We used multivariable logistic and linear regressions for comparison., Results: After excluding men with testosterone levels <300 ng/dL, 3673 men met inclusion criterion. Only 146 (4%) of men had a testosterone >800 ng/dL. When compared to men with normal testosterone, men with high testosterone had similar rates of sleep disorders, urinary symptoms, and depression. Men with elevated testosterone had higher hematocrit regression coefficient (βi 1.30, 95% confidence interval [CI] 0.69-1.90 P < .01), AST (βi 8.48, 95% CI 0.31-16.66, P = .04) and ALT (βi 12.23, 95% CI 0.70-23.77, P = .04) compared to men with normal testosterone., Conclusion: No association was found between higher endogenous testosterone levels and adverse events associated with testosterone therapy. Men with higher testosterone had increased hematocrit, but this was not clinically significant. This challenges what is considered a safe target for testosterone therapy and prompts future prospective studies to delineate the safety of elevated endogenous and exogenous modulated levels of testosterone., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling., Methods: Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors., Results: Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191)., Conclusion: Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To examine the association between selective serotonin reuptake inhibitor (SSRI) use and semen quality., Methods: We performed a retrospective review of all men undergoing semen analysis (SA) for fertility evaluation from 2002-2020 at a single academic medical center. Men were excluded if they had prior exposure to spermatotoxic medications, clomiphene citrate, gonadotropins, selective estrogen receptor modulators, or medical conditions known to impact male fertility. SSRI exposure was defined by an outpatient prescription within 90 days prior to any semen test. Differences between men with and without SSRI exposure were assessed with Wilcoxon rank sum for continuous variables and chi-squared testing for proportions. Univariable and multivariable linear regression models were fit to evaluate the relationship between SSRI use and individual semen parameters, controlling for age at the time of the semen analysis and non-SSRI drug use., Results: A total of 8861 men were identified, of whom 153 men (1.7%) were exposed to SSRIs prior to SA. Median age was 35 years (interquartile range: 32-39) and was similar between groups (P = .999). Non-SSRI medication use was significantly higher in men taking SSRIs (78.4% vs 23.3%, < .001). On univariable and multivariable analyses, SSRI exposure was not associated with differences in semen volume, sperm concentration, motility, total motile sperm count, or normal morphology., Conclusion: In adult men undergoing fertility evaluation, SSRI exposure was not associated with impaired semen parameters. These data may help inform reproductive counseling and medical decision-making regarding SSRI use in men seeking paternity., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To determine prevalence of hyperprolactinemia and prolactinoma among men presenting for initial fertility evaluation., Methods: We performed a retrospective review of men presenting for initial fertility evaluation at a tertiary care, academic health system between 1999 and 2018. Men with measured prolactin levels were analyzed to determine prevalence of hyperprolactinemia and prolactinoma. We compared clinical characteristics of men with and without hyperprolactinemia. Univariable and multivariable analysis were used to determine factors associated with hyperprolactinemia. We assessed effects of hyperprolactinemia and prolactinoma on testosterone levels, semen parameters and pregnancy outcomes after treatment., Results: A total of 3101 men had serum prolactin level measured. 65 (2.1%) had hyperprolactinemia. Patients with hyperprolactinemia had lower testosterone (median 280 ng/dL vs 313 ng/dL, P = 0.038) and lower total motile sperm count (median 7.0 million vs 34.7 million, P = 0.001) compared to men without hyperprolactinemia. 43.1% of men with hyperprolactinemia had oligospermia vs 21.5% of men without hyperprolactinemia (P<0.001). Univariable analysis demonstrated that men with elevated luteinizing hormone (LH) (OR 1.077, P = 0.001) and follicle-stimulating hormone (FSH) (OR 1.032, P = 0.002) were more likely to have hyperprolactinemia. Men with oligospermia were more likely to have hyperprolactinemia (OR 2.334, P = 0.004). On multivariable analysis, neither hormone parameters nor oligospermia were associated with elevated prolactin (P>0.05). Of the 65 men with hyperprolactinemia, 11 (17%) were diagnosed with a prolactinoma, resulting in an overall prevalence of 11 in 3101 (0.35%)., Conclusion: The overall prevalence of prolactinoma in our cohort of men undergoing fertility evaluation was 35-fold higher than the prevalence in the general male population., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To determine whether health-conscious men are more likely to be concerned about infertility and self-initiate semen analysis at a laboratory/clinic or through a direct-to-consumer at-home product without a health care provider recommendation., Methods: Cross-sectional survey conducted online via ResearchMatch.org between November 2019 and January 2020. Men age 18 and older without children (n = 634) were included for analysis. Outcomes were likelihood of self-initiating a semen analysis, prevalence of infertility concern., Results: Of the 634 participants, 186 expressed concern about infertility but only 29% were likely to discuss these concerns with a health care provider. More men would self-initiate a semen analysis using an at-home product than through a traditional laboratory/clinic (14.2% vs 10.4%, P = .04). Odds of self-initiating a traditional semen analysis were higher for men concerned about low testosterone (odds ratio [OR] 2.30, 95% confidence interval [CI] 1.12-4.74, P = .023) and infertility (OR 3.91, 95% CI 2.14-7.15, P <.001). Self-initiating an at-home semen analysis was associated with concern for low testosterone and infertility as well as middle age (age 40-59: OR 3.02, 95% CI 1.16-7.88, P = .024) and fitness tracker use (OR: 1.95, 95% CI 1.12-3.39, P = .018)., Conclusion: Many men were unlikely to discuss infertility concerns with a health care provider. Middle aged men and those who used fitness trackers were more likely to self-initiate fertility evaluation through at-home semen analysis. Concern about low serum testosterone was pervasive and strongly associated with concern for being infertile and self-initiating a semen analysis of any kind., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts., Methods: Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed., Results: We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed., Conclusions: Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To characterize the epidemiology of male factor infertility and identify which types of providers are treating infertile men in the United States., Materials and Methods: The National Ambulatory Medical Care Survey was queried between 2006 and 2016 for all ambulatory care visits. Men with a diagnosis of infertility were identified by international classification of disease coding. Comorbidities, demographic and visit information were abstracted from the patients' medical record by a combination of trained surveyors and physicians. The survey data was weighted to create nationally representative estimates, and a combination of Chi-squared and Student's t-tests were utilized to determine significance., Result(s): Among the 8.7 billion patient visits between 2006 and 2016, there were 3,422,000 male encounters with a diagnosis of male factor infertility. The most common provider type for male factor infertility encounters was urology (42.12%) followed by primary care (39.79%), gynecology (7.05%) and all other provider types (11.01%). A significant number of men seen for infertility had comorbidities such as cancer (115,000 men, 3.36%) diabetes (267,000 men, 7.81%), depression (301,000 men, 8.8%), and active tobacco use (857,000 men, 30.3%)., Conclusion: In a nationally representative sample, more than 50% of ambulatory care visits for male factor infertility were not seen by urologists. These men also had a significant number of comorbidities for a relatively young cohort, emphasizing the importance of multidisciplinary care for men with a diagnosis of infertility., (Published by Elsevier Inc.)

Objectives: To evaluate the extent to which erectile dysfunction (ED) is managed by urologists versus non-urologists. We sought to characterize the epidemiology, diagnosis, and outpatient treatment of ED using a nationally representative cohort., Methods: We examined all male patient visits between 2006 and 2016 in the National Ambulatory Medical Care Survey, a survey designed to provide a nationally representative estimate of ambulatory visits in the United States. Distribution of ED diagnoses among physician specialties was determined. Demographic, clinical, and treatment characteristics of men with ED seeing urologists versus non-urologists were compared using chi-squared tests., Results: Among the 170,499 patient visits analyzed, 1.2% were associated with a diagnosis of ED, which translated into 3,409,244 weighted visits annually. Visits for ED were predominantly seen by urologists (58.0%) and family practitioners (26.2%). Men visiting non-urologists for ED were more likely to be younger than 65 (77.4% vs 52.9%, P < .05). Men seeing urologists for ED more frequently had an active cancer diagnosis (24.2% vs 2.8%, P < .05). Non-urologists more readily ordered or reordered phosphodiesterase-5 inhibitors for men with ED (66.62% vs 50.77%, P < .05). Advanced therapies such as intracavernosal injections and intra-urethral agents were almost exclusively ordered by urologists compared to non-urologists (2.72% vs 0.25%, P < .05)., Conclusion: Almost half of all ED visits were seen by non-urologist providers, who were much less likely than urologists to order advanced pharmacologic therapies. This difference in prescribing patterns presents an opportunity for interdisciplinary collaboration and education to ensure that all patients seeking treatment for ED are receiving guideline-based care., (Published by Elsevier Inc.)

Objective: To describe trends in the characteristics of urologic surgeons performing vasectomy over time., Methods: We performed a retrospective, cross-sectional study examining surgeon characteristics for case logs from the American Board of Urology between 2004 and 2013. We used generalized estimating equations with a log link and negative binomial distribution to examine demographic differences (gender, rural location, and surgeon volume) in the number of vasectomies surgeons performed over time., Results: Between 2004 and 2013, 5316 urologists had case logs collected within the 7-month certification window. The majority of these surgeons self-identified as general urologists (82.8%), and a small proportion identified as andrology and infertility specialists (1.7%). Across all years, the median number of vasectomies performed per certifying surgeon during the study period was 14 (interquartile range 6-26). The majority of vasectomies were performed by high-volume surgeons (≥ 26 vasectomies) ranging from 49.2% to 66.9% annually, whereas the proportion performed by low-volume (≤ 5 vasectomies) surgeons ranged from 3.3% to 6.6% annually. Male surgeons performed vasectomies 2.20 times more frequently than female surgeons (95% confidence interval 1.93-2.49; P <.0001) across the study period with no evidence to suggest this gap changed over time (gender-year interaction 1.01 [95% confidence interval: 0.97-1.06; p = .576])., Conclusion: While the majority of urologists performing vasectomy identify as general urologists, there appears to be a focus on vasectomy practice among a small number of high-volume surgeons. Furthermore, while the number of female surgeons performing vasectomies increased, a gender gap persists in the proportion of vasectomies performed by females., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy of men's and women's cancer awareness campaigns using internet relative search volume (RSV) as a surrogate for public interest., Methods: We utilized Google Trends to determine the RSV for "breast cancer," "prostate cancer," and "testicular cancer" from 2010 to 2017. Baseline annual RSV for each cancer was calculated as the median annual RSV, exclusive of the awareness month period. RSV was then determined for each cancer-specific awareness month and compared to baseline. The primary outcome was 2-fold rise in RSV above baseline., Results: Breast Cancer Awareness Month led to a significant increase in cancer-specific RSV in October each year during the study period (mean increase 180.1%). In contrast, none of the men's cancer awareness campaigns led to a significant increase in cancer-specific RSV in any year during the study period. RSV for prostate cancer increased by 2.4% and 4.1% in September and November, respectively. RSV for testicular cancer increased by 9.3% and 6.2% in April and November, respectively., Conclusion: Men's cancer awareness campaigns did not increase cancer-specific RSV, whereas Breast Cancer Awareness Month consistently increased RSV. While additional metrics are needed to evaluate the efficacy of public health campaigns, the current data suggest the need for new approaches to generate public interest in male-specific malignancies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To determine the distribution of semen parameters among adolescent and adult males presenting for fertility preservation., Methods: A retrospective, cross-sectional cohort study of adolescent males age 11-19 who underwent semen analysis for fertility preservation at 3 centers in 2 countries with a comparison cohort of adult men presenting for fertility preservation. Prevalence of azoospermia and distribution of semen parameters was compared across groups., Results: A total of 197 adolescents and 95 adults underwent semen analysis for fertility preservation. Azoospermia was present in 17 (8.6%) adolescents and 3 (3.2%) adults. There was decline in the prevalence of azoospermia with increasing age. After exclusion of patients with azoospermia, the adolescent and adult cohorts were comprised of 180 and 92 patients, respectively. Median age at presentation among adolescents vs adults was 16.5years (interquartile range [IQR] 15.2-17.6) and 30.8years (IQR 22.7-43.8), respectively. Median semen volume was 1.0mL (IQR 0.5-2.0) vs 2.5mL (IQR 1.5-3.5), P <.001. Median sperm concentration was 30million/mL (IQR 10-57) vs 39million/mL (IQR 14-57), P = .2. Median sperm motility was 39% (IQR 20-55) vs 45% (IQR 35-55), P = .01. Median total motile sperm count was 11million (IQR 1.4-33) for adolescents vs 29million (IQR 13-69) for adults, P <.001., Conclusion: Young adolescent males had higher prevalence of azoospermia and lower semen parameters compared to adults. In conjunction with physical examination, Tanner stage, and specific clinical context, these data can help to inform patients and their families about potential for fertility preservation, even in very young adolescent patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To examine trends in international medical graduate (IMG) representation within urology and compare these trends to those of other specialties., Methods: Urology match data were obtained from the American Urological Association from 1987 to 2015. IMG representation among residencies was extracted from reports on Graduate Medical Education published in Journal of the American Medical Association from 1978 to 2013. We analyzed trends in the number of IMG urology applicants, match rates in urology for IMGs vs US medical graduates, and the annual percentage of IMGs among all urology residents vs residents of other specialties., Results: Between 1987 and 2015, 6790 applicants matched into urology. The number of positions offered increased by 24% (224 to 295) between 1987 and 2015. However, the number of IMG urology applicants did not increase accordingly (r = -0.55, P = .78). Match rates for US students and IMGs ranged from 68% to 91% and 6% to 33%, respectively. From 1978 to 2013, the proportion of IMGs across all specialties remained relatively stable (25% to 27%), whereas the proportion of IMGs in urology decreased substantially (27% to 5%)., Conclusion: The proportion of IMGs in urology training has dramatically decreased over time and remains lower than most other specialties. IMGs are critical to urology as they can assist in meeting workforce demands, contribute diversity to the workplace, and help to propel the field forward through urologic research. Further efforts should be directed toward understanding the unique needs of IMG residents and helping them to navigate the challenges of practicing in a foreign country., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial randomized men to usual care or annual prostate-specific antigen (PSA) screening for 6 yr and digital rectal examination for 4 yr. This trial found no difference between the intervention and usual care arms of the study in the primary end point of prostate cancer (PCa)-specific mortality. The PLCO trial results have had a major impact on health policy and the rate of PSA screening in the United States. We analyzed the 13-yr screening and outcomes data from the 151 participants who died of PCa in the screening arm of the trial to better understand how randomization to screening failed to prevent PCa death in these men. We found that of these men, 81 (53.6%) either were never screened as part of the trial or had an initial positive screen. Only 17 (11.3%) of those who died reached year 6 of the trial with a PSA <4.0 ng/ml. The men who died in the screening arm were also older at study entry than the average PLCO participant (66 vs 62 yr; p < 0.001). Our analysis should inform the interpretation of the PLCO trial and provide insight into future trial design., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Radical cystectomy is the gold-standard management for muscle-invasive bladder cancer, and there is debate concerning the comparative effectiveness of robotic-assisted (RARC) versus open radical cystectomy (ORC)., Objective: To compare utilization, perioperative, cost, and survival outcomes of RARC versus ORC., Design, Setting, and Participants: We identified bladder urothelial carcinoma treated with RARC (n=439) or ORC (n=7308) during 2002-2012 using the Surveillance, Epidemiology, and End Results Program-Medicare linked data., Intervention: Comparison of RARC versus ORC., Outcome Measurements and Statistical Analysis: We used propensity score matching to compare perioperative and survival outcomes, including lymph node yield, perioperative complications, and healthcare costs., Results and Limitations: Utilization of RARC increased from 0.7% of radical cystectomies in 2002 to 18.5% in 2012 (p<0.001). Women comprised 13.9% versus 18.1% (p=0.007) of RARC versus ORC, respectively. RARC was associated with greater lymph node yield with 41.5% versus 34.9% having ≥10 lymph nodes removed (relative risk 1.1, 95% confidence interval [CI] 1.01-1.22, p=0.03) and shorter mean length of hospitalization at 10.1 (± standard deviation 7.1) d versus 11.2 (± 8.6) d (p=0.004). While inpatient costs were similar, RARC was associated with increased home healthcare utilization (relative risk 1.14, 95% CI 1.04-1.26, p=0.009) and higher 30-d (p<0.01) and 90-d (p<0.01) costs. With a median follow-up of 44 mo (interquartile range 16-78), overall survival (hazard ratio 0.88, 95% CI 0.74-1.05) and cancer-specific survival (hazard ratio 0.91, 95% CI 0.66-1.26) were similar., Conclusions: RARC provides equivalent perioperative and intermediate term outcomes to ORC. Additional long-term and randomized studies are needed for continued comparative effectiveness assessment of RARC versus ORC., Patient Summary: Our population-based US study demonstrates that robotic-assisted radical cystectomy has similar perioperative and survival outcomes albeit at higher costs., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate changes over time in female representation among urology residents compared to those within other specialties., Materials and Methods: Urology match data were obtained from the American Urological Association from 1996 to 2015. Trends in match rates of male and female urology applicants were assessed. Data for gender representation among residencies were extracted from reports in the Journal of the American Medical Association from 1978 to 2013. We compared the annual percentage of women among urology residents vs residents of other specialties over time., Results: Mean number of male vs female urology applicants per year was 285.0 ± 27.1 vs 76.5 ± 21.8 (P < .001). There was no statistically significant difference in the mean successful match rate of male vs female applicants (68.2% vs 66.6%, P = .36). From 1978 to 2013, the proportion of female residents across all specialties rose from 15.4% to 46.1%, whereas female residents in urology rose from 0.9% to 23.8%. Between 2009 and 2013, obstetrics and gynecology and orthopedics had the highest and lowest average proportion of women, respectively (80.7% and 13.5%). The largest growth occurred in urology among all other specialties (P < .001), with an 11-fold increase seen during the study period., Conclusion: Male and female applicants to urology residency have similar match rates. Although urology demonstrated the greatest fold-increase in proportion of women among all specialties during the study period, women have remained a minority among urology residents. Gender representation within urology is a reflection of many factors and demonstrates a need for further improvement., (Copyright © 2016 Elsevier Inc. All rights reserved.)